Rudolphs pediatrics self assessment and board review, 22e (2014)

Cristofalo, MD, MPH Assistant Professor of PediatricsDepartment of PediatricsJohns Hopkins University School of MedicineBaltimore, Maryland Chapter 5 Colleen Hughes Driscoll, MD Assistan

PEDIATRICS

SELF-ASSESSMENT AND BOARD REVIEW

the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the stan-dards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, read-ers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work

is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance

in connection with new or infrequently used drugs

Professor of Pediatrics, Epidemiology, and Biostatistics

Chief, Division of General Pediatrics

Department of PediatricsUniversity of California, San Francisco

UCSF Benioff Children’s Hospital

Philip R Lee Institute for Health Policy Studies

San Francisco, California

Consulting EditorsHilary M Haftel, MD, MHPE

Professor of PediatricsDepartment of Pediatrics and Communicable Diseases

University of MichiganAnn Arbor, Michigan

Sunitha V Kaiser, MD

Assistant Professor of Pediatrics

Department of PediatricsUniversity of California, San Francisco

San Francisco, California

Julie Stein O’Brien, MD

Assistant Professor of Pediatrics

Department of PediatricsUniversity of California, San Francisco

San Francisco, California

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To Cewin, Alexandra, Abigail, Annie, and Binko

Contributors ix

Foreword xv

Preface xvii

Acknowledgments xix

1 Fundamentals of Pediatrics 1

Laura L Sisterhen, Natalie J Burman, and D Micah Hester 2 Health Promotion and Disease Prevention 17

Ada M Fenick 3 Nutrition 43

Michael D Cabana and Cewin Chao 4 Abuse, Neglect, and Violence 55

Christopher C Stewart 5 Newborn 65

W Christopher Golden, Elizabeth A Cristofalo, Bernadette A Hillman, and Colleen Hughes Driscoll 6 Principles of Adolescent Care 103

Lauren B Hartman and Sara M Buckelew 7 Development and Behavior 122

Martin T Stein and Julie Stein O’Brien 8 The Acutely Ill Infant and Child 143

Christine S Cho, Jerusha Pearson-Lev, and Cornelia Latronica 9 The Chronically Ill Infant and Child 180

John I Takayama and Sunitha V Kaiser 10. Transplantation 194

Marie H Tanzer and David B Kershaw 11. Disorders of Metabolism 202

Ayesha Ahmad 12. Clinical Genetics and Dysmorphology 220

Angela Scheuerle 13. Immunologic Disorders 237

Hilary M Haftel 14 Allergic Disorders 245

Alan P Baptist and Aimee Leyton Speck 15 Rheumatologic Disorders 262

Hilary M Haftel 16 Musculoskeletal Disorders 280

Hilary M Haftel 17 Infectious Disease 294

Dylan C Kann, Duha Al-Zubeidi, Erica Pan, Sunitha V Kaiser, and Michael D Cabana 18 Disorders of the Skin 335

Erin F.D Mathes, Diana Camarillo, Ann L Marqueling, Vikash Oza, Julie C Philp, Deepti Gupta, and Barrett J Zlotoff 19 Disorders of the Ear, Nose, and Throat 368

Anna K Meyer and Kristina W Rosbe 20 Disorders of the Oral Cavity 378

Susan Fisher-Owens and Michael D Cabana 21 Disorders of the GI Tract 386

Kristin L Van Buren, Haley C Neef, and Eric H Chiou 22 Disorders of the Liver 418

Sarah Shrager Lusman and Haley C Neef 23. Disorders of the Blood 434

James Huang and Tannie Huang 24. Neoplastic Disorders 462

Ashley Ward and Robert Goldsby 25 Disorders of the Kidney and Urinary Tract 480

Kartik Pillutla and Erica Winnicki 26 Disorders of the Heart 493

Alaina K Kipps and Laura A Robertson 27 Disorders of the Respiratory System 519

Amy G Filbrun, Danielle M Goetz, and Nanci Yuan 28 Endocrinology 547

Andrea K Goldyn and Todd D Nebesio 29 Neurology 571

Amy A Gelfand and Kendall B Nash 30 Disorders of the Eyes 596

Lance M Siegel and Tina Rutar Index 617

CONTENTS

Division of Allergy and Clinical Immunology

University of Michigan School of Medicine

Ann Arbor, Michigan

Chapter 14

Sara M Buckelew, MD, MPH

Associate Professor of Pediatrics

Department of Pediatrics

University of California, San Francisco

San Francisco, California

Chapter 6

Kristin L Van Buren, MD

Assistant Professor of Pediatrics

University of California, San Francisco

San Francisco, California

Chapter 1

Michael D Cabana, MD, MPH

Professor of Pediatrics, Epidemiology, and Biostatistics

Chief, Division of General Pediatrics

Department of Pediatrics

University of California, San Francisco

UCSF Benioff Children’s Hospital

Philip R Lee Institute for Health Policy Studies

San Francisco, California

Chapters 3, 17, and 20

Diana Camarillo, MD

Pediatric Dermatology FellowDepartment of DermatologyUniversity of California, San FranciscoSan Francisco, California

Chapter 18

Cewin Chao, MS, RD, MBA

Director, CTSI Bionutrition CoreDepartment of MedicineUniversity of California, San FranciscoSan Francisco, California

Chapter 3

Eric H Chiou, MD

Assistant Professor of PediatricsDepartment of Pediatrics Baylor College of Medicine Houston, Texas

Chapter 21

Christine S Cho, MD, MPH, MEd

Assistant Professor of Pediatrics and Emergency MedicineDepartments of Pediatrics and Emergency Medicine University of California, San Francisco

San Francisco, California

Chapter 8

Elizabeth A Cristofalo, MD, MPH

Assistant Professor of PediatricsDepartment of PediatricsJohns Hopkins University School of MedicineBaltimore, Maryland

Chapter 5

Colleen Hughes Driscoll, MD

Assistant Professor of Pediatrics Department of PediatricsUniversity of Maryland School of MedicineBaltimore, Maryland

Chapter 5

Ada M Fenick, MD

Assistant Professor of PediatricsDepartment of PediatricsYale School of MedicineNew Haven, Connecticut

Chapter 2

CONTRIBUTORS

Amy G Filbrun, MD, MS

Clinical Assistant Professor of Pediatrics

Department of Pediatrics and Communicable Diseases

University of California, San Francisco

San Francisco, California

Chapter 20

Amy A Gelfand, MD

Clinical Instructor

Departments of Pediatrics and Neurology

University of California, San Francisco

San Francisco, California

University of California, San Francisco

San Francisco, California

University of California, San Francisco

San Francisco, California

Chapter 18

Hilary M Haftel, MD, MHPE

Professor of PediatricsDepartment of Pediatrics and Communicable DiseasesUniversity of Michigan

Ann Arbor, Michigan

Chapters 13, 15, and 16

Lauren B Hartman, MD

Instructor of PediatricsDepartment of Pediatrics University of California, San FranciscoSan Francisco, California

Chapter 5

James Huang, MD

Professor of PediatricsDepartment of Pediatrics University of California, San FranciscoSan Francisco, California

Chapter 23

Tannie Huang, MD

Clinical InstructorDepartment of PediatricsUniversity of California, San FranciscoSan Francisco, California

Chapter 23

Sunitha V Kaiser, MD

Assistant Professor of PediatricsDepartment of PediatricsUniversity of California, San FranciscoSan Francisco, California

Chapters 9 and 17

University of California, San Francisco

San Francisco, California

Chapter 17

David B Kershaw, MD

Associate Professor of Pediatrics

Department of Pediatrics and Communicable Diseases

Stanford Medical School

Palo Alto, California

Chapter 26

Cornelia Latronica, MD

Attending Physician

Department of Pediatric Emergency Medicine

Children’s Hospital and Research Center Oakland

Oakland, California

Chapter 8

Sarah Shrager Lusman, MD

Assistant Professor of Pediatrics

Department of Pediatrics

Columbia University Medical Center

New York, New York

Chapter 22

Ann L Marqueling, MD

Assistant Clinical Professor

Departments of Dermatology and Pediatrics

Stanford University School of Medicine

Palo Alto, California

Chapter 18

Erin F.D Mathes, MD

Assistant Professor of Dermatology

Department of Dermatology

University of California, San Francisco

San Francisco, California

Chapter 18

Anna K Meyer, MD

Assistant Professor of Otolaryngology

Department of Otolaryngology

University of California, San Francisco

San Francisco, California

Chapter 19

Kendall B Nash, MD

Assistant Professor of Pediatrics and NeurologyDepartments of Pediatrics and NeurologyUniversity of California, San FranciscoSan Francisco, California

Ann Arbor, Michigan

Chapters 21 and 22

Julie Stein O’Brien, MD

Assistant Professor of PediatricsDepartment of PediatricsUniversity of California, San FranciscoSan Francisco, California

Chapter 7

Vikash Oza, MD

Pediatric Dermatology FellowDepartment of DermatologyUniversity of California, San FranciscoSan Francisco, California

Chapter 17

Jerusha Pearson-Lev, MD

Attending PhysicianDenver Emergency Center for ChildrenDenver Health

Denver, Colorado

Chapter 8

Julie C Philp, MD

Pediatric Dermatology Fellow

Department of Dermatology

University of California, San Francisco

San Francisco, California

Chapter 18

Kartik Pillutla, MD

Attending Pediatric Nephrologist

Dell Children’s Medical Center of Central Texas

University of California, San Francisco

San Francisco, California

Chapter 26

Kristina W Rosbe, MD

Professor of Clinical Otolaryngology

Department of Otolaryngology

University of California, San Francisco

San Francisco, California

Chapter 19

Tina Rutar, MD

Assistant Professor of Pediatrics and Ophthalmology

Departments of Pediatrics and Ophthalmology

University of California, San Francisco

San Francisco, California

Chapter 30

Angela Scheuerle, MD

Clinical Assistant Professor

McDermott Center for Human Genetics

University of Texas (UT) Southwestern

Medical Director

Texas Birth Defects Research Center

UT Houston School of Public Health

University of California, Los Angeles (UCLA)

Los Angeles, California

Chapter 1

Aimee Leyton Speck, MD

FellowDepartment of MedicineDivision of Allergy and Clinical ImmunologyUniversity of Michigan School of MedicineAnn Arbor, Michigan

Chapter 14

Martin T Stein, MD

Professor of PediatricsDepartment of Pediatrics University of California, San Diego (UCSD)San Diego, California

Chapter 7

Christopher C Stewart, MD

Associate Professor of PediatricsDepartment of Pediatrics University of California, San FranciscoSan Francisco, California

Chapter 4

John I Takayama, MD, MPH

Professor of Clinical PediatricsDepartment of Pediatrics University of California, San FranciscoSan Francisco, California

Chapter 9

Marie H Tanzer, MD

Attending Pediatric NephrologistDepartment of Pediatrics Maine Medical Partners Pediatric Specialty CarePortland, Maine

Chapter 10

Ashley Ward, MD

Assistant Professor of PediatricsDepartment of PediatricsUniversity of California, San FranciscoSan Francisco, California

Chapter 24

Erica Winnicki, MD

Assistant ProfessorDepartment of PediatricsUniversity of California, DavisSacramento, California

Chapter 25

Stanford University School of Medicine

Palo Alto, California

Chapter 27

Barrett J Zlotoff, MD

Associate ProfessorDepartment of DermatologyUniversity of New MexicoAlbuquerque, New Mexico

Chapter 18

True knowledge exists in knowing that you know nothing.

Socrates

FOREWORD

xv

In the 22nd edition of Rudolph’s Pediatrics, we provided a

comprehensive review of the development of the normal infant

and child and of the disorders and diseases that may affect

them A prime objective was the consideration of the biologic

basis for normal and abnormal development and for the

changes associated with the disease With this vast amount of

background information, it may be difficult to define the role

of etiological factors and the significance of various clinical

observations in differential diagnosis and management

In this Self-Assessment and Board Review, Dr Cabana and

his colleagues follow the tradition of the great teacher Socrates

by providing a series of questions designed to assist the

reader in analyzing the importance of abnormal physiologic,

biochemical, genetic, and other features in pediatric disorders

and to highlight clinical features that aid in differential

diagnosis Stimulating questions allow the student to assess

the extent of their own knowledge Brief explanations illustrate key points, and readers are conveniently referred to the core textbook for in-depth learning We congratulate the authors for creating this valuable resource to help all of us evaluate our knowledge of pediatrics, and thereby assure we provide children with the best care possible

Colin D Rudolph, MD, PhD

Clinical Professor Department of Pediatrics University of California, San Francisco

Abraham M Rudolph, MD Professor Emeritus Department of Pediatrics University of California, San Francisco

Rudolph’s Pediatrics 22nd Edition Self-Assessment and Board

Review builds upon the 22nd edition of the textbook, Rudolph’s

Pediatrics Although Rudolph’s Pediatrics is already a key

resource and reference, our goal was to create a companion

book that would allow readers to more easily and quickly

absorb the contents presented in Rudolph’s Pediatrics

As a result, this book contains over 1500 questions that

place the content in Rudolph’s Pediatrics in a clinical context

While the textbook presents a general overview of different

pediatric topics, this Self-Assessment and Board Review book

actively questions the reader about the clinical application of

such material in terms of the epidemiology, pathophysiology,

presenting symptoms, clinical decision making, therapeutics,

and prognosis of different pediatric disorders This book is

designed for practicing pediatricians who need to quickly

assess their knowledge of pediatrics, by topic This book then

gives the reader a quick reference to the pertinent sections in

Rudolph’s Pediatrics to reinforce the reader’s knowledge about

the topic

We have been able to enlist an outstanding group of pediatric clinician educators who have provided a collection

of challenging questions for each chapter These questions

highlight the key clinical issues from Rudolph’s Pediatrics In

addition, the thirty topics presented in this book parallel the

thirty topics and chapters in Rudolph’s Pediatrics This feature

allows readers the opportunity to focus on any one specific topic, based on their own learning needs

We are sure that you will find this review book both comprehensive and challenging We hope you find this book indispensable as part of your preparation and review for the Pediatric Board examination

Michael D Cabana, MD, MPH San Francisco, California

We would like to thank the team at McGraw-Hill who have

helped us throughout this process, including Dominik

Pucek, Christine Barcellona, and Alyssa Fried A special

thanks to Abraham Rudolph, MD, who introduced us to

the McGraw-Hill team and entrusted us with developing

this project In addition, thanks to Nancy Tran, from the

University of Vermont, who helped us edit and prepare

this text

We would also like to thank our respective Chairs, Donna

Ferriero, MD, at the University of California, San Francisco

ACKNOWLEDGMENTS

xix

(UCSF), and Valerie Castle, MD, at the University of Michigan for their support and leadership We acknowledge our medical students, residents, and trainees who keep

us sharp with their questions and excited about our work with their enthusiasm UCSF Benioff Children’s Hospital and C.S Mott Children’s Hospital are very special places

to work Every single day, outstanding patient care, clinical education, new discoveries, and advocacy for children are applied to provide the best possible care for children, families, and communities

Laura L Sisterhen, Natalie J Burman, and D Micah Hester

Fundamentals of Pediatrics

CHAPTER 1

the clinic is implementing an electronic medical

record system for the first time You have been asked

to give input on behalf of the other pediatricians in

your clinic that will allow the system to better serve

your patients and facilitate communication between

providers caring for your patients Which of the

following recommendations will best serve your patient

population well into the 21st century?

a. A diagnosis list that is reduced to contain

pediatric-specific diagnoses only

b. An automated system that selects the best empiric

antibiotic for specific infectious diseases

c. An electronic reminder system that notifies you

when labs are abnormal and contains family contact

information to relay the results

d. A system that can be highly individualized to

allow each provider to routinely choose the asthma

treatment approach that works best for each

individual provider

e. The ability to generate a lab requisition printout for

a patient to carry with him or her to the laboratory

respiratory therapists have asked that you give a talk

on aerosolized treatments for bronchiolitis Specifically,

they have asked the following question: “In infants

hospitalized with bronchiolitis, does 3% hypertonic

saline compared with 0.9% saline result in decreased

length of stay?” Which of the following study titles is

most likely to best answer the clinical question?

a. Nebulized hypertonic saline without adjunctive

bronchodilators for children with bronchiolitis: a

retrospective cohort study

b. Nebulized 3% hypertonic saline solution treatment

in hospitalized infants with viral bronchiolitis: a

randomized, double-blind, controlled trial

c. Hypertonic saline in the treatment of acute bronchiolitis in the emergency department:

a case series

d. Nebulized hypertonic saline and recombinant human DNAse in the treatment of pulmonary atelectasis in newborns

e. Inhaled hypertonic saline in infants and toddlers with bronchiolitis: short-term tolerability, adherence, and safety

authors enrolled 50 infants admitted to the hospital with bronchiolitis and randomized them to receive either treatment with a nasal decongestant or placebo Following administration of the nasal drops, a research assistant measured the change in oxygen saturation One parent withdrew consent; thus, 49 of the 50 patients completed the study The results showed that there was no statistical difference in change in

oxygen saturation between groups ( P > 05) As part of

your discussion, you critically appraise the evidence Which of the following is the most accurate statement?

a. The results of the study could have been affected by

a small sample size

b. The results demonstrate that topical nasal decongestants are not effective in reducing length of stay for infants with bronchiolitis

c. Infants who were randomized to the treatment group, but did not receive the drug due to tachycardia, should not have been included in the treatment group during analysis

d. This is a cohort study that is able to equalize study groups for known, but not unknown, confounding factors

e. The number of patients lost to follow-up was unacceptable

1-4 You receive a daily e-mail summarizing the latest

pediatric research on your handheld device One

study on bullying behaviors catches your attention On

further reading, you learn that the study was based

on an analysis of a nationally representative,

cross-sectional survey of 15,000 students in grades 6 to 10

Involvement in bullying and self-reported physical

symptoms such as headaches, stomachaches, backaches,

dizziness, and sleeping difficulties were measured The

results showed that 15% of the students were involved

in bullying as a victim and/or as a bully at least once

a week Students who reported at least 1 or more

physical symptoms, which occur several times a week,

were 3 times more likely to be involved in frequent

bullying incidents, as compared with students who did

not experience frequent symptoms What is the most

accurate conclusion you can determine from the results

of this study?

a. Involvement in bullying causes stress in

school-aged children resulting in physical symptoms of

headaches, stomachaches, and backaches

b. Physical symptoms of headaches, stomachaches, and

backaches in children cause them to engage in more

frequent bullying

c. In preadolescent and adolescent students in grades

6 to 10, the incidence of bullying behaviors is 15%

d. There is an association between bullying behaviors

and somatic complaints that merits further

investigation with a stronger observational study

e. Physical symptoms of headaches, stomachaches, and

backaches in children are the result of being a victim

of frequent bullying

to collaborate in a study The researcher would like

to examine the effect of a new prethickened formula

on gastroesophageal reflux disease in infants As a

clinician, you are most interested in patient-centered

outcomes as opposed to disease-oriented outcomes

Which of the following study designs will you

recommend as the most clinically useful study?

a. A double-blind, randomized trial of prethickened

versus standard formula in infants with symptomatic

reflux comparing the reduction of pain symptoms

and weight gain in the 2 groups

b. An observational study of infants measuring their

symptom severity score before and after initiating

the new prethickened formula

c. A double-blind, randomized trial examining the effect of the prethickened formula on gastroesophageal reflux using scintigraphic measurement of gastric emptying time

d. A placebo-controlled crossover study examining the effects of the thickened formula on gastroesophageal reflux using intraluminal impedance

e. A placebo-controlled, randomized trial of the thickened formula using direct laryngoscopy

to examine for the presence of reflux-related extraesophageal tissue injury

3-year-old daughter to establish care for the infant She is concerned about the baby’s slow weight gain

As you begin to discuss breast-feeding with the mother, the 3-year-old sister begins telling you about her new doll that she brought to the visit and she wants you

to examine the abrasion on her knee from a fall this morning While you find the 3-year-old compelling and adorable, it is difficult to focus the encounter on the new baby and his mother’s concerns What is the most effective way to redirect this patient encounter?

a. Ask the mother if the toddler can go out into the waiting room with her grandmother, since the grandmother is visiting to help with the new adjustment

b. Ask the toddler if she helps her mother to take care of the new baby and then ask her to hold onto the pacifier while the baby breast-feeds so you can evaluate the latch

c. Discuss with the mother that this is typical sibling rivalry behavior and give her several strategies on how to assist the toddler with the adjustment

d. Excuse yourself from the mother and baby to examine the toddler’s abrasion and give her appropriate reassurance

e. Speak directly to the toddler and tell her she needs

to be quiet because today it is her brother’s turn and she will get her turn at her appointment

Fundamentals of Pediatrics

her kindergarten entrance physical When you walk

into the room, the 5-year-old begins crying and says,

“No, I don’t want a shot.” As you begin to engage the

family, which of the following statements is the best

choice for promoting relationship building with the

child and her mother?

a. As you enter the room, you take a few minutes

to read the electronic medical record and begin

reviewing her past medical history and previous

clinic notes

b. As you walk into the room, you make direct eye

contact with the mother and introduce yourself to

her, making sure you learn the mother’s first name

and then introduce yourself to the patient

c. You efficiently go through any new concerns, review

the past medical history, and begin your physical

examination so you can stay on schedule

d. You introduce yourself to the child first and say,

“Wow, you are already to start kindergarten! You

must be so excited Did you get any new school

supplies yet?”

e. You sit down on the examination table right next to

the girl and say, “Don’t worry, we don’t do any shots

in this room The nurse will take you to the shot

room when we are all done here.”

parents state she has been refusing to walk the past

couple of days One week ago she had a febrile illness

They do not report any trauma On observation, you

see that she is in no respiratory distress She cries as you

approach her for examination While auscultating her

chest, she leans down to bite your arm As part of your

assessment, you want to assess her reflexes and motor

strength What is the most appropriate next step to

complete your examination?

a. Defer the examination until she is more cooperative

with your neurological examination

b. Explain to the child that she must do what the

doctor says or we cannot help her feel better

c. Enlist the family to make her follow your directions

and hold her head if necessary

d. Ask for a physical therapy consult for a more

comprehensive evaluation

e. Use toys to encourage her to stand while blowing

bubbles that she can reach for and pop

scheduled asthma recheck You scheduled a 10-minute visit and are behind in your schedule She is very chatty about her recent divorce, and her daughter’s sleep disturbances, bedwetting, and itchy rash on her arms that seems to be getting worse with the over-the-counter cream they are using You note that since the last visit, she has made 2 emergency department visits for wheezing Today, you want to obtain spirometry and manage her asthma, which is not well controlled What

is the best response in order to plan the visit with the patient, and prioritize the asthma?

a. “Let’s make sure we talk about her asthma and eczema It sounds like you also want to make sure

we cover her bedwetting If we can’t get to the other concerns, let’s schedule another visit to discuss her adjustment to the divorce.”

b. “When a visit is scheduled for an asthma recheck, the only diagnosis I have time to address today is your daughter’s asthma The bedwetting will probably get better once she has adjusted to the divorce.”

c. “You are concerned about issues that are not related

to your daughter’s asthma, which is the most important diagnosis for us to discuss I’ll refer your daughter to a counselor to help her adjust to the recent divorce.”

d. “Next time you call for an appointment, let them know that you need an hour with me, so I can address all of your concerns at once.”

e. “Your divorce seems to be having an effect on your daughter, given all of her symptoms How were you hoping I could help?”

obesity 4 years ago based on her BMI percentile at her 6-year-old well visit She comes in today with her mother for her 10-year-old well visit and continues to have an elevated BMI When you ask the patient how confident she is on a scale of 1 (not at all confident) to

10 (very confident) that she can cut soda out of her diet, she tells you “6.” Choose the best response to her answer based on your knowledge of motivational interviewing

a. “Six, which is really great I am really glad you chose a higher number today than you did at your last visit.”

b. “That is excellent; I can tell you are ready to make a change.”

c. “Okay, why not lower?”

d. “Do you think you are ready to make a change?”

e. “How confident are you that you can cut out fast food?”

1-11 A 15-year-old girl is accompanied by her father for

a sport’s physical As you walk into the examination

room, you sense there is some tension between the

adolescent and her father After completing the past

medical history with most of the answers from her

father and a few mumbled answers from the adolescent,

you politely ask the father to wait in the waiting room

so that you can complete the physical examination You

explain to him this procedure is routine for all patients

over age 12 Once he leaves the room, you begin the

HEADSS examination During this assessment, she

says, “My father and I don’t really get along He always

wants to be in my business.” Which of the following

questions would be the best response to her statement?

a. “Does he invade your privacy?”

b. “Don’t you think he is just concerned for your

safety?”

c. “Do you feel overly restricted by his concerns for

you?”

d. “When was the last time he got into your business?”

e. “Why do you think he is concerned about your

business?”

in your office She comes in today with her mother

who is frustrated by the frequency of her cough While

taking the history, you ask if anyone in the household

smokes tobacco She responds, “I’m tired of being asked

about my smoking every time I bring my daughter to

the doctor.” What is the best reflective statement in

response to her statement during the encounter?

a. “You do know that the best thing you can do for

your health is to quit smoking, don’t you?”

b. “I’m sorry, I apologize I won’t ask you about your

smoking anymore.”

c. “May I give you some information about

secondhand smoke exposure?”

d. “Do you know how harmful smoking in the home is

to your daughter’s health?”

e. “It sounds like you are frustrated by health care

providers asking if you smoke.”

accompanied by his mother Early into the visit, she discloses to you that there is marital discord in the home and she is struggling with the behavior that is

exhibited by her son As you review the Bright Futures

checklist of items to discuss at this visit, you realize that you cannot address all of the guidelines recommended for a 2-year-old well visit during the 20-minute appointment Which clinic system would be most important to have in place so that you can best meet the needs of this child and his mother?

a. A handout discussing multiple safety concerns appropriate for 2-year-olds

b. A list of community resources that support families coping with stress

c. An established referral network that includes developmental pediatricians

d. Developmental surveillance questions included on your well visit encounter form

e. Reach Out and Read volunteers to enhance early literacy in the waiting room

today for a follow-up visit from her recent admission You have been following her since her abnormal newborn screen for elevated trypsinogen She initially had surgery as an infant for bowel obstruction and was closely followed for poor weight gain until age 2 Over the past year, she has become colonized with a mucoid

strain of Pseudomonas and was admitted for the first

time for intravenous and inhaled antibiotics to attempt

to eradicate her colonization and treat pneumonia As you are starting to feel overwhelmed by her changing medical condition and the stress the admission has put

on the family, you stop to think about your role in her care as a general pediatrician Within the larger system

of care for this patient’s disease, which of the following

is your responsibility?

a. Coordinating her follow-up bronchial aspiration procedure through the pediatric anesthesia department

b. Ensuring she is on the clinic registry as a high-risk patient to receive the annual influenza immunization once it becomes available

c. Optimizing her outpatient antibiotic and pulmonary treatment regimen for her current respiratory status

d. Organizing multidisciplinary clinics to address all of her cystic fibrosis needs

e. Selecting appropriate educational materials and providing cystic fibrosis education to teach her about the progression of her condition

Fundamentals of Pediatrics

clinic by his father for a concern of fever The infant

has been feeding well, but a little fussier than usual

His father became concerned and obtained a rectal

temperature this morning at 101.3°F (38.5°C) and

brought the baby in for an evaluation Using a

systems-based approach, which of the following is the best

choice in proceeding to care for this infant?

a. Conferring with your colleague down the hall, to see

what she thinks you should do for this infant

b. Discussing with the father if he feels comfortable

taking the infant home with a follow-up

appointment in 24 hours

c. Referring to your institutional clinical practice

guideline on fevers that was last updated 10 years

ago

d. Requesting your nurse recheck the temperature to

ensure the infant is currently febrile

e. Using the online source for National Guideline

Clearinghouse to find the most recent guideline for

fever in an infant

and busy summer day, you check your inbox to find

5 patient phone calls to address before you can leave

for the day Three of the 5 calls are regarding difficulty

scheduling appointments with you for well and

follow-up visits These 3 families have been in your

practice for quite a while This problem has become a

routine issue and you contemplate what can be done

to fix this Which of the following changes would be

most effective in improving access for your established

patients?

a. Ask your front desk staff to complete all registration

paperwork and insurance verification in the waiting

room so that any problems can be addressed before

the patient is in the examination room

b. Begin charting patient demand for appointments to

determine which patient needs are and aren’t being

met by your current appointment templates

c. Confirm that your supply storage room is fully

stocked so you can go to a central place to obtain all

necessary supplies during patient encounters

d. Increase the length of your appointments from 20 to

30 minutes so you can accomplish more at each visit,

reducing the need for follow-up visits

e. Increase the number of acute appointments in your

summer templates so that families who need

same-day care are appointed more quickly, leaving more

available appointments in the future for routine care

structure- and process-based experience to based training Six core competencies have been embraced by multiple medical education organizations and many accrediting bodies These competencies consist of medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice Which of the following statements best describes the reason for this new emphasis on competency-based training and physician performance?

competency-a. A report put out by the Institute of Medicine that outlined this new structure for medical education

b. The Accreditation Council for Graduate Medical Education (ACGME) developed these to address the need for improved quality of care

c. The Flexner report issued by the Carnegie Foundation set forth this approach to medical education

d. The Joint Commission requests to see these

6 competencies evaluated for each physician within

a health care organization

e. The need for teaching hospitals to be more financially solvent in an increasingly competitive medical marketplace

Education (ACGME) has outlined 6 core competencies

to guide assessment of all residents within a residency program Which of the following is the correct competency–description pair?

a. Interpersonal and communication skills—Residents must be able to provide compassionate, appropriate, and effective patient care for the treatment of health problems and the promotion of health

b. Medical knowledge—Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social–behavioral sciences and demonstrate the ability to apply this knowledge to patient care

c. Patient care—Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals

d. Practice-based learning and improvement—Residents must demonstrate an awareness of and a responsiveness

to the larger context and system of health care, as well

as the ability to call effectively on other resources in the system to provide optimal health care

e. Systems-based practice—Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning

1-19 You are a hospitalist in an academic center This

morning you conducted bedside work rounds with

your medical team Your medical team consists

of medical students, interns, residents, a bedside

nurse, a respiratory therapy coordinator (R.T.),

dietician, and social worker Your first patient was a

9-year-old admitted for an asthma exacerbation and

oxygen requirement After the intern completes his

presentation, you examine the patient, elicit concerns

of the family, and discuss discharge criteria The R.T

reports the patient’s response to treatment and suggests

that the team prescribe the inhaled corticosteroid that

is the preferred medication on the patient’s insurance

formulary The nurse reports that the patient’s father is

interested in quitting smoking and the team refers him

to the free, statewide tobacco dependence treatment

program During this discussion, the intern updates a

discharge instruction summary that will be faxed to the

patient’s primary care provider The residency program

director asks you to identify the competencies of the

Accreditation Council for Graduate Medical Education

(ACGME) that you incorporated during rounds this

morning The rounding encounter described above best

describes which ACGME competency?

for an elective procedure The father informs the

anesthesiologist that his child is deaf and the child

becomes very upset when he cannot read lips The

father explains that last time his son had surgery, he

became very combative when he was taken from his

parents for induction of anesthesia Because he reads

lips, and all the staff members were wearing surgical

masks over their mouths, he became very anxious

Which response by the anesthesiologist best expresses

the principles of patient- and family-centered care?

a. “We all have to wear surgical masks for infection

control and your son is getting older, so he should be

able to handle his fears better than the last time.”

b. “You know that we will be very nice to Johnny and

he has nothing to be afraid of We will take very

good care of him.”

c. “Would it help your son if you accompany him to induction of anesthesia and if we wait to place our surgical masks on until he is comfortable?”

d. “I’m sorry the last operation was such an unpleasant experience; we’ll make sure that your son receives the best care this time.”

e. “It’s alright, you don’t have anything to worry about;

it won’t take us long to induce sedation and he won’t remember anything.”

about patient- and family-centered care You describe the key principles of family-centered care including respect, information sharing, participation, collaboration, and flexibility Which of the following organizational processes best supports the philosophy

of family-centered care?

a. The emergency department encourages family members to be present for resuscitations even if they

do not wish to witness the resuscitation

b. Family members are allowed in the intensive care unit at all hours except during work rounds and nursing change of shift

c. A multidisciplinary committee develops educational materials about the dangers of secondhand smoke for parents who smoke tobacco

d. Two patient and family advisors serve as nonvoting members on the Patient Care Committee and the Bioethics Committee

e. Two patient and family advisors are invited to join

a working group that is beginning an improvement project to improve medication reconciliation

Fundamentals of Pediatrics

part of your team orientation with the new students,

you discuss the process for conducting family-centered

rounds Which of the following best reflects

family-centered care principles?

a. You instruct the students and/or bedside nurses to

make sure parents are awake between 10 and noon,

when your team will be conducting walk rounds on

all patients

b. Your team will conduct bedside rounds on all

patients with 1 exception: when the patient is

admitted for the evaluation of child maltreatment

syndrome

c. The students present the vital signs, physical

examination, and laboratory findings outside the

patients’ rooms Following the hallway presentation,

the team enters the room to give the family the plan

and answer any questions they may have

d. You ask the students to obtain permission from the

patients and families to round in the patient’s room

When the team enters the room, they knock on the

door, introduce themselves, and invite the caregivers

to participate in the discussion of their child

e. During rounds at the bedside, you teach families

how to take care of their child with special health

care needs and model this family teaching for the

students

a pediatric clinic in Galveston, Texas Because this town

is located on the Gulf of Mexico, it has an increased

risk of being impacted by a devastating hurricane

As a part of your new role, you have been asked to

be the disaster preparedness representative from the

clinic to work directly with a local hospital committee

to plan for disaster response Your role also includes

dissemination of information to your partners on their

role in disaster preparedness Which of the following

is the responsibility of every pediatrician in disaster

preparedness?

a. Ensure all of your patients have been vaccinated

against hepatitis A because the last disaster in your

area rendered all drinking water unsafe and there

was a hepatitis A epidemic

b. Become a member of the Incident Command

System, which facilitates the efficient coordination

and mobilization of resources necessary in a disaster

response

c. Discuss the development of a disaster plan with

the families of patients with special health care

needs because of their dependence on specialized

medications and equipment

d. Focus all of your preparedness on hurricanes since this is the natural disaster threat to your population and other disasters are much more rare

e. Take a continuing medical education course on diagnosis and treatment of posttraumatic stress disorder in children to increase your proficiency in its management

lecture on disaster preparedness as a part of their section on disaster medicine Which of the key points is most accurate about the role of the pediatrician and the effects of disasters on pediatric patients?

a. Because of the rapid growth and development of infants, they are less susceptible to toxins than older children

b. Children are very resilient to disasters and, therefore, should not be diagnosed with posttraumatic stress disorder

c. Children inhale and ingest larger quantities of contaminated air, food, and water for their weight than adults do

d. Discussion in the household about violence, death, and disaster increases fear of disasters and decreases the resilience of children

e. Pediatricians are not skilled to address the community on disaster preparedness; this should be left to the local health authorities

2-month checkup After doing a thorough examination, you state, “Now, it is time to start Anna on her

immunizations Would you like that in 1 shot that contains many vaccines, or we can give multiple shots with 1 vaccine in each?” Ms B states that she does not wish to get any vaccinations She has read that they may lead to autism and other health-related problems You should respond to Ms B accordingly:

a. “I’m sorry that you feel that way, but I will not be able to continue as your child’s pediatrician.”

b. “I’m concerned that the media may have distorted your understanding of vaccinations.”

c. “I would like to talk to you more about the scientific basis of this, and in the meantime we can wait on starting the immunizations.”

d. “You are putting your child and the society at serious risk, and I will need to call in Child Protective Services if you do not agree to the immunizations right now.”

e. “I will have to have a social worker come evaluate this situation to determine if you are fit to continue

to care for your child.”

1-26 Julie is 15 years old and has been brought into the

emergency department after fainting during volleyball

practice You are the ED physician seeing Julie, and

during the examination you ask whether Julie has been

sexually active and would like to get a pregnancy test

Julie hesitates to disclose information and asks whether

she can rely on you to not tell her mother

You should respond to Julie accordingly:

a. “What you say to me I take to be confidential

However, there are some things I must report to

others.”

b. “I’m sorry, but as a minor, I have to tell your parents

everything that we talk about.”

c. “Are you afraid of your parents for some reason?

Should I call in Child Protective Services?”

d. “The confidentiality of our discussion is safe with

me In fact, no one else need know what we talk

about in here.”

e. “You are too young to be sexually active Abstinence

is the best way to avoid unwanted pregnancy and

sexually transmitted diseases.”

because breathing is becoming increasingly difficult

He is 12 years old and his parents are members of the

Jehovah’s Witness faith If the surgery is not performed,

Billy will eventually require a ventilator, tracheostomy,

and may lose lung function altogether The surgeon

is unwilling to do the surgery without consent to use

blood products if necessary, but Billy’s parents refuse to

consent for blood products

The surgeon should:

a. Do the surgery anyway, and just not use blood even

if Billy’s medical condition warrants it

b. Before performing the surgery, get a court order to

allow blood products during the surgery, but only

use them if necessary

c. Perform the surgery as an “emergent” issue without

parental consent for blood products

d. Ask Billy what he would want and follow Billy’s

wishes as a mature minor

e. Get a social worker to evaluate whether the parents

are fit to continue to care for Billy

Justin is brought in by his babysitter, who is on summer break from college Justin, who is 6 years old, was riding his bike when he lost control and fell He was not wearing his helmet, but the babysitter insists that

he was “not going too fast.” You notice that Justin has a cut that looks to need stitches, and his head has a large bump on it The babysitter says that she cannot get hold

of Justin’s parents on their cell phones; she has no other phone numbers for the parents or family members A nurse attempts to contact the parents as well, but is not successful, either

The nurse asks you what you will do next You decide to:

a. Wait until the parents can be contacted to do anything other than keeping Justin comfortable as possible

b. Track down phone numbers of Justin’s grandparents

in order to gain their consent for any medical treatments

c. Find a hospital administrator to consent to treatments for Justin

d. Get consent from the babysitter to admit Justin so that he can be properly monitored until his parents can be found

e. Close Justin’s wounds and get any tests and scans necessary to be sure that his injuries are properly diagnosed Debrief the parents once they are located

Hodgkin disease While undergoing his first round of chemotherapy, he begins to look on the Internet for alternative therapies because the current medications make him sick and tired all the time Once the first phase

is over, he decides that he will instead take vitamins he has read about online His parents are not sure what is best for Bobby, but they homeschooled him precisely because they wanted their son to learn to be independent and make decisions for himself So, even though they would like to see him continue his current therapy, they

do not want to go against their son’s wishes

Bobby’s health care team should:

a. Stop all treatments and allow Bobby to pursue the alternative therapies he desires

b. Convince Bobby’s parents that he is wrong, and gain their consent to continue chemotherapy

c. Talk further with Bobby in order to address his concerns and possibly develop a plan that can provide both chemotherapy and adjuncts that meet his interests

d. Get a court order to force Bobby to have chemotherapy

e. Stop chemotherapy, but provide the alternative therapies to Bobby so as to maintain the patient–professional relationship

Fundamentals of Pediatrics

school boyfriend He is in the military and is out of

the country Nicole lives with her parents while he is

away One night, on her way home from an evening

class her car is hit by another vehicle She ends up in

the intensive care unit on a ventilator She has spinal

cord and brain injuries, but the physician believes she

is making neurological progress and should recover

decision-making capacity, though she may not walk

again Her parents have been at her bedside throughout

Now, 2 weeks into her hospital stay, the physicians

want to talk about a tracheostomy to secure Nicole’s

airway long-term The need for a tracheostomy is not

emergent, at this point in time

The physician should:

a. Try to contact Nicole’s husband abroad to get his

consent for the procedure

b. Since Nicole is a minor, obtain consent for the

procedure from Nicole’s parents

c. Since Nicole cannot speak for herself, have a judge appoint a guardian ad litem who can objectively evaluate whether the procedure is in Nicole’s best interest

d. Wait a few more weeks to see if Nicole recovers decisional capacity, giving her the chance to decide for herself

e. Get a court to declare Nicole incompetent and appoint one of her family members as surrogate

ANSWERS

Answer 1-1 c

The emphasis of patient care has changed from the 20th

century to the 21st century to become more patient- and

family-focused Patients and their families desire increased

access to information, more timely information, and quality

care that is evidence-based By incorporating an alert system

that notifies a provider of an abnormal result with easy access

to the family’s contact information allows a physician to readily

respond to abnormal results and notify the family of the result

and the intended next step This system change also facilitates a

timely and reliable method of alerting physicians of potentially

concerning information

A diagnosis list limited to pediatric diagnoses may facilitate

easier billing on a routine basis, but it can be overly limiting

As more children are being diagnosed with what were

traditionally considered adult diseases, it is important to allow

for the flexibility of changing epidemiology

While a system that automatically determines empiric

antibiotics for specific infectious diseases might be helpful,

it would be very difficult for this to be reflective of local

antibiotic-resistant patterns and may not address other

factors associated with infectious diseases that could require

other empiric treatment (eg, a child who is diagnosed with

lymphadenitis may have a young kitten at home leading to a

diagnosis of Bartonella , rather than Group A Streptococcus , and

would require different antibiotic coverage)

Flexibility in electronic medical records is helpful to allow

physicians to document in a way that works efficiently for each

provider However, with medicine moving toward an emphasis

on quality care, approaches to treatment should be based on

evidence in research rather than individual physician preferences

Lastly, the generation of a lab requisition through an electronic medical record saves time for a physician, but there

is still a chance of the requisition getting lost before a patient arrives at the lab Ideally the lab order should be electronically delivered to the lab through a secure network to avoid human error in transporting the order

(Page 1-2, Section 1: Fundamentals of Pediatrics, Chapter 1: Role of the Pediatrician)

Answer 1-2 b

The respiratory therapists have developed a complete and answerable clinical question in the PICO (patient or problem, intervention, comparison, outcome) format Framing the question in this format allows one to conduct a practical and focused search of the literature Well-done systematic reviews,

such as in the Cochrane Database of Systematic Reviews , may be

sufficient to answer the question However, a physician wanting

to keep up with the most up-to-date information would want

to search for original studies published since the review was conducted

A prospective, blinded comparison trial is the most useful

to determine the efficacy of an intervention Randomization is

an effective strategy to minimize known, as well as unknown, allocation bias Therefore, a study using a randomized, double-blind, controlled trial design would be the most appropriate publication to retrieve and critically appraise in order to answer the question

Cohort studies are limited by the possibility of confounders that may influence the association being studied For example, consider a cohort study that examined the medical records for

length of stay among infants hospitalized for bronchiolitis The

study would be limited by the fact that there may have been

an unmeasured difference (such as educational level of the

caregivers or the initial severity of illness) between the groups

of infants who received 3% saline and those who did not

receive saline Unmeasured differences may have affected their

length of stay and biased the results A case series would not

be useful to assess efficacy, because of the small sample size,

lack of randomization, and lack of a comparison group The

other titles address safety of hypertonic saline and treatment

of pulmonary atelectasis, but do not include the outcome of

interest (length of stay)

(Page 3-4, Section 1: Fundamentals of Pediatrics, Chapter 2:

Decision Making: Use of Evidence-based Medicine)

Answer 1-3 a

In this “negative” study that shows no statistically significant

difference between groups, it is possible that a real difference

in change of oxygen saturation between study groups was

missed There are 2 possible errors that can occur with any

study (see the display table below) In a “positive” study, the

study results may suggest a difference exists between therapies,

when a difference does not actually exist This situation is

a Type I error and is mitigated by assessing the P value (the

chance of a Type I error) However, in the case above, the

study is a “negative” study In this situation, there is the risk

of a Type II error: the authors suggest that no difference exists

and it is possible that a difference may actually exist In this

situation, it is important to assess if the study had an adequate

sample size (or power) to avoid this error In general, a sample

size calculation and justification should be included in the text

of the published study to allow the reader to critically appraise

this possibility

Study Results

Actual Truth

No Difference Exists Difference Exists

Difference exists Type I error (Correct)

No difference exists (Correct) Type II error

Answer b is incorrect because the length of stay was not

the primary outcome measure of this study This study was

a randomized controlled trial that permitted the authors to

limit the effects of both known and unknown confounding

factors In a randomized trial, patients should be analyzed

in the groups to which they were randomized, allowing

investigators to determine how the potential treatment

performs in the real world Thus, answers c and d are

incorrect A high dropout rate or withdrawal rate can

compromise the validity of any study In this case, only

1 of the patients withdrew from the study; however, the 98% follow-up and completion rate was reasonable for this study (Page 4, Section 1: Fundamentals of Pediatrics, Chapter 2: Decision Making: Use of Evidence-based Medicine)

of disease is defined as the number of new cases of a disease that occur during a specified period of time in a population

at risk A cross-sectional study cannot determine incidence of disease because the population is surveyed at one moment in time, not over time For this reason, answer c is incorrect (Page 4, Section 1: Fundamentals of Pediatrics, Chapter 2: Decision Making: Use of Evidence-based Medicine)

Answer 1-5 a

Answer a is the most clinically useful study A double-blind, placebo-controlled, randomized trial is most appropriate to examine the efficacy of a therapeutic intervention, such as

a prethickened formula Patient-centered outcomes focus

on measures that can be identified by the patient such as hospitalization rate, pain severity, or length of stay Disease-oriented outcomes include improvement in laboratory values, or other physical measurements such as intraluminal impedance or pH probe monitoring of gastric reflux Direct laryngoscopy would be invasive to the patient and the effect

of reflux on laryngeal tissue injury is another disease-oriented outcome measure Therefore, answers c, d, and e are incorrect Answer b is incorrect because it is an observational, before-and-after study without a control group Without a control group, the investigators cannot attribute the improved symptoms to the prethickened formula Another confounding factor could have influenced the desired outcome

(Page 3, Section 1: Fundamentals of Pediatrics, Chapter 2: Decision Making: Use of Evidence-based Medicine)

Answer 1-6 b

Communication with families in the pediatric clinic can

be challenging when there are siblings present during an encounter In addition, time of family transitions such as the birth of a new baby can compound the situation In this case, it is essential to give the mother–infant dyad appropriate attention to address their interaction and not

be overly distracted by the older sibling Because the older sibling is accustomed to seeing a pediatrician in the context

of being the patient, she is feeling left out She may also

be experiencing some jealousy of the new baby According

to Miller’s habit of humanism, a physician must identify multiple perspectives in each encounter, reflect on possible

Fundamentals of Pediatrics

conflicts that could help or hinder forming a relationship

with the patient, and choose to act altruistically

Answer b is the best choice because this allows you to

validate the importance of the big sister’s new role in an

age-appropriate manner, but also redirect the visit toward the

mother’s weight concern Answer a will not validate the sibling

and may create more delays in the visit if she becomes upset

and refuses to go to the waiting room Answer c may be helpful,

but detracts from the focus of the visit, the newborn This may

be helpful to address at the end of the visit if there is additional

time and especially if it is a concern for the mother Answer d

may appease the sibling’s desire for your attention, but also

detracts from the visit Answer e may be viewed as scolding the

child and can hinder the relationship you are establishing with

the mother In addition, the sibling is not being validated and

will likely continue to compete for attention

(Page 6, Section 1: Fundamentals of Pediatrics, Chapter 3:

Communication)

Answer 1-7 d

Building a relationship with a scared child can be very

difficult, especially when his or her fears, such as getting an

immunization, are well founded There are several verbal

and nonverbal communication skills that can be used to

assist in this process Answer d is the best choice because

you are directly engaging the patient by acknowledging

her on an age-appropriate level that relates to the purpose

of the visit Answers a and c are incorrect because you are

avoiding establishing rapport with the mother or the child

by immediately delving into the purpose of the visit without

showing any interest in the 2 other people in the room

Answer b is an appropriate way to address the parent, but it

would be better to address the patient, followed by the parent,

to better establish rapport with the patient and encourage her

participation in her own medical care on an age-appropriate

level Answer e is unlikely to be effective because the child is

already scared of what might happen when you enter the room

and this can be further exacerbated by quickly approaching

her personal space and then discussing the impending

immunizations that she is so worried about

(Page 9, Table 3-4, Section 1: Fundamentals of Pediatrics,

Chapter 3: Communication)

Answer 1-8 e

The examination of a 2-year-old requires physician flexibility

and ability to adjust the physical examination techniques as

needed in order to engage the child It is developmentally

normal for a willful and anxious toddler to refuse being

examined and appear uncooperative Appropriate

developmentally based communication during the 2-year-old

examination includes play By providing toys and using bubbles

as a distraction technique, the physician will be more likely to

assess whether or not a toddler can bear weight or pull to stand

than simply asking her to stand up and walk

It is not appropriate to defer the examination as it is important to identify whether or not the child is weak and to exclude neurological causes of her refusal to walk A 2-year-old

is too young to engage in discussions about cooperating with your examination, so answers a and c are incorrect A physical therapy consult may be appropriate depending on the diagnosis but not in the initial assessment during a clinic visit

(Page 6, Section 1: Fundamentals of Pediatrics, Chapter 3: Communication)

Answer 1-9 a

Applying the Four Habits Model of communication will help

to build and sustain this relationship with Mrs Johnson and her daughter The first habit in this model is termed “invest

in the beginning.” Investing in the beginning of the encounter includes skills such as creating rapport quickly, eliciting the patient’s (or parent’s) concerns, and planning the visit Planning the visit with Mrs Johnson includes prioritizing her asthma, which is not well controlled By negotiating the agenda for the encounter, you can acknowledge her concerns while making

it clear that you have limited time for the visit Answers b and c do not acknowledge mother’s concerns, while answer d

is unrealistic in a busy practice Answer e acknowledges the stress on the family and is an appropriate way to explore the impact the divorce has had on the family; however, it does not prioritize the asthma for this visit

(Page 6-8, Section 1: Fundamentals of Pediatrics, Chapter 3: Communication)

Answer 1-10 c

Based on the motivational interviewing technique using readiness rulers, following her rating with a question of “why not lower?” helps you to address her strengths in her perceived ability to make this change A further response can be followed

up by another question of “why not higher?” to determine what her perceived barriers in addressing this change might

be Answer a is a positive answer but doesn’t really address her readiness to make a change Answer b is incorrect because it makes the assumption she is ready to make a change without addressing any barriers she may face Answer d doesn’t take into account the principle of using the readiness ruler, but does attempt to address readiness to change However, this question

is not open-ended and may elicit a socially desired response rather than the truth Answer e changes the subject and avoids more in-depth knowledge about whether the patient is ready to address her soda intake

(Page 14, Section 1: Fundamentals of Pediatrics, Chapter 4: Interviewing Techniques)

Answer 1-11 e

Communicating with adolescents can feel more difficult than communicating with a parent of a young child, but similar interviewing techniques can be used Open-ended answers

require engagement between the patient and provider When

discussing behavior, it is recommended that 4 open-ended

questions be used for every closed-ended question Answer e

is the best response because it is the only question that is

open-ended and will allow you to explore what the adolescent

meant by her statement Her answer will be richer in content

and will help you to determine if this is just a concerned father,

an overly controlling father, or an adolescent who might be

engaging in some problematic behavior

Answer a is a closed-ended question and will not produce

much information Answer b is a leading question and implies

you are taking the side of her father that may compromise your

rapport with the patient Answer c may be a useful question as

you learn more about what she meant by the initial statement,

but this question may best be used as a follow-up to more

open-ended questions Answer d is another closed-ended

question that will be unlikely to yield any useful information

(Page 13, Section 1: Fundamentals of Pediatrics, Chapter 4:

Interviewing Techniques)

Answer 1-12 e

A motivational tool that can be used in brief clinical

encounters is the reflective statement The reflective statement

is a restatement of the content or feeling expressed by the

patient or caregiver It is especially helpful in response to

meeting resistance from a patient or caregiver The ability to

phrase statements that stimulate a conversational response is a

crucial skill in reflective listening

The other responses are not reflective statements

Answer b prevents the opportunity of the physician to conduct

motivational interviewing or assist the parent in quitting

smoking in the future Answer a has a concluding tone that is

designed to elicit a confirmatory “yes” response It prevents

the physician from eliciting any thoughts from the parent

about her smoking Answer c is an appropriate response to

a parent who is not ready to quit smoking, but is open to

discussion about his or her smoking; however, it is not a

reflective statement

(Page 14, Section 1: Fundamentals of Pediatrics, Chapter 4:

Interviewing Techniques)

Answer 1-13 b

Office systems to support clinical care assist a pediatrician

in providing quality care that meets parents’ needs Because

all of the recommended topics for each well visit cannot be

addressed in the usual 20-minute appointment, the focus of the

appointment must elicit parents’ concerns, identify psychosocial

risk factors, incorporate appropriate anticipatory guidance

regarding development, and be tailored to the family’s needs

Systems can be designed to assist the pediatrician in both

accomplishing some of the preventive care guidelines before the

child is seen and improving the efficiency of time spent with

the patient Answer b is correct because it is specific to this

family’s needs, which addresses the mother’s concerns, and will

help to further identify psychosocial risk factors that cannot be addressed by the pediatrician during the well-child visit Answer a is helpful in addressing appropriate anticipatory guidance but is not directed specifically to the concerns that are addressed by the mother Answer c is incorrect because there is no evidence that this child has developmental delay Answer d is incorrect because the recommended practice

is to do targeted developmental screening rather than superficial developmental surveillance In addition, this can

be accomplished prior to the encounter with a designated developmental screening tool Answer e is not specific to this family’s need, but is an evidence-based intervention that promotes early literacy

(Page 15, Section 1: Fundamentals of Pediatrics, Chapter 5: Systems of Practice and Office Management)

Answer 1-14 b

Pediatricians are increasingly caring for patients with chronic diseases While these patients often have multiple providers to care for their highly specialized needs, the general pediatrician still plays a valuable role The chronic care model ( Figure 5-1 ) shows how the community, the health system, the patient, and the physician all have a role in improving patient outcomes Answer b is the best answer This answer is a good example of using clinical information systems to facilitate prompt patient care to implement clinical guidelines and track patients who do not receive timely follow-up Preventive medicine, such as the administration of an annual influenza immunization, is well within the purview of a primary care pediatrician Answers

a and c may be necessary to optimize her therapy, but the coordination of care is best managed by the specialist who is most skilled at performing the necessary procedure and most experienced at determining the optimal therapy for this specific condition Answer d is another example of a benefit to the patient that incorporates a proactive team, but would best be coordinated by the pulmonologist who directly partners with the involved subspecialists Answer e again is an important part

of informing the patient how to be an active participant in his

or her care, but this role would be better filled in the setting of a specialized clinical center for cystic fibrosis

(Page 15-16, Section 1: Fundamentals of Pediatrics, Chapter 5: Systems of Practice and Office Management)

Answer 1-15 e

Approaching common clinical problems with a systems approach that is evidence-based links to higher-quality and cost-effective care Fever in an infant is a common clinical problem for which practice guidelines exist Guidelines for common clinical problems, such as fever in an infant, can

be found through the National Guideline Clearinghouse, American Academy of Pediatrics, and many children’s hospital Web sites In addition, many hospitals and practices often develop their own specific clinical pathways, standing order sets, references to national guidelines, parent or patient

Fundamentals of Pediatrics

information sheets, and discharge goals Answer e is the best

answer because it is an efficient way to find up-to-date clinical

guidelines that are original sources

Answer a may be helpful if your colleague is well versed in

this particular guideline, but it bypasses a systems approach and

doesn’t ensure the most evidence-based answer to the clinical

question Answer b does not incorporate a systems approach

and is not supported by fever guidelines for this age patient

Answer c is a systems approach, but a guideline that is over

10 years old is unlikely to contain the most current

evidence-based approach and should be verified with another online

source If this older guideline contains a reference to the parent

guideline, that can be used to guide an online search for the

most current recommendation Answer d is incorrect because

it does not apply a systems approach and could potentially

distract a provider for properly caring for a young febrile infant

(Page 16-17, Section 1: Fundamentals of Pediatrics, Chapter 5:

Systems of Practice and Office Management)

Answer 1-16 b

Clinic access and efficiency have become more evidence-based

with a trend toward open or advanced access The goal for open

access is to predict the demand and respond to it effectively

by matching supply with demand, while reducing inefficiency

This can be enabled by having same-day availability not only

for acute visits but also for well-child care and follow-up

care This decreases waits in the system and allows patients

increased access to their own physician, improving patient

satisfaction and quality of care According to Table 5-2

(Principles of Advanced Access), answer b is correct because

it lays the groundwork for transitioning to an open access

approach to office management By determining the specific

demand of your patient population over a period of time, this

can be used to predict the demand so that the supply can be

adjusted accordingly

Answer a is incorrect because this strategy may decrease

efficiency Ideally registration and insurance can be completed

prior to the appointment by mailings and phone verification

so that the patient can be seen by the provider on arrival to the

waiting room Delays in registration and insurance verification

lead to delays in physician schedules that are difficult to

overcome once the schedule becomes delayed Answer c is

incorrect because the supplies should be readily accessible and

stocked in the examination rooms, not a central storage room

Well-stocked examination rooms help to avoid inefficiencies

in direct patient care Answer d is incorrect because longer

appointments mean a decreased number of total appointments in

a day The need for follow-up is rarely averted by increased length

of appointments Answer e is incorrect because the demand for

appointments in the summer is typically shifted more toward well

care, rather than acute The winter time may need to be adjusted

to include more acute visits and less well visits

(Page 17, Table 5-2, Section 1: Fundamentals of Pediatrics,

Chapter 5: Systems of Practice and Office Management)

Answer 1-17 b

Answer b is correct because the 6 core competencies initially described by the ACGME were a response to the Institute of

Medicine report To Err Is Human This report highlighted the

significant gaps in the quality of care for patients within the United States The medical education community felt that there was a need to ensure that physicians were competent in a variety of areas It was no longer sufficient to expect physicians

to be competent based on a specific quantity of time in various training experiences, which were often evaluated by global assessments

Answer a is incorrect because the Institute of Medicine report did not recommend a specific approach to medical education;

it just highlighted the problems that contributed to poor quality

of care and proposed that leaders in medical education have a role in addressing the quality of care issue Answer c is incorrect because Flexner report was completed in 1910 and changed medical education significantly at that time to standardize the student’s educational experience Medical education did not change significantly again until the Institute of Medicine report that was followed by the ACGME’s move to focus on outcomes-based training This emphasis became highlighted during the last decade of the 20th century and the beginning of the 21st century Answer d is incorrect because the Joint Commission does not evaluate these competencies in physicians It does ask health care organizations to use role-specific competency assessment for all clinical staff in the organization Answer e is incorrect because there is no direct financial incentive for implementing these 6 competencies into resident or physician assessment, despite the need for financial solvency to keep an organization in existence (Page 17-18, Section 1: Fundamentals of Pediatrics, Chapter 6: Core Competencies)

Answer 1-18 b

Answer b is correct according to Table 6-1 as the description of the competency of medical knowledge Answer a is incorrect because the description belongs to patient care Answer c is incorrect because the description belongs to interpersonal and communication skills Answer d is incorrect because the description belongs to systems-based practice Answer e is incorrect because that is the description for practice-based learning and improvement

(Page 18, Table 6-1, Section 1: Fundamentals of Pediatrics, Chapter 6: Core Competencies)

Answer 1-19 c

Answer c is correct because although multiple competencies may be assessed in 1 patient encounter, the rounds described above best fit with systems-based practice evaluation To show achievement in systems-based practice, residents must demonstrate an interdisciplinary approach to patient care

In the scenario above, the respiratory therapist and the patient’s nurse were effectively part of the health care team and addressed important issues that may impact the patient’s

asthma control If the patient’s medication is not covered by

insurance, adherence to prescribed therapy may be diminished

The patient will also have more difficulty controlling her

symptoms if she is exposed to tobacco smoke By referring the

patient’s caregiver to a statewide tobacco dependence treatment

program, the team demonstrated the ability to access other

resources in the health care system to provide optimal chronic

disease management

Lastly, the team recognized the importance of continuity of

care by communicating the discharge instructions to the patient’s

medical home Medical knowledge is not demonstrated by the

residents in this scenario as they did not express understanding

of scientific knowledge and its application to patient care

Practice-based learning and improvement is not correct

because there is no evidence during rounds that the residents

conducted self-evaluation of their patient care Interpersonal

and communication skills may have been demonstrated during

the encounter, but the effective exchange of information is

not described above Professionalism and adherence to ethical

principles is also not addressed in the scenario

(Page 18, Section 1: Fundamentals of Pediatrics, Chapter 6:

Core Competencies)

Answer 1-20 c

Patient- and family-centered care is best described by the

principles of respect, information sharing, participation,

collaboration, and flexibility Fundamental to the model

of patient- and family-centered care is the concept that

partnership with the family will result in improved patient

care outcomes Of all the response options, proposing that the

parent accompany the child to induction of anesthesia and

being flexible about when to wear the surgical masks is the

most patient- and family-centered response

Reassuring the parent that the medical team will be kind,

efficient, or provide the best care is one approach when

a family member voices a concern about his or her child;

however, it does not demonstrate a partnership with the parent

Another family-centered approach would be to ask the family

what has worked well in the past and negotiate a plan with the

family to reduce their child’s anxiety about not being able to

communicate with the health care team

(Page 19, Section 1: Fundamentals of Pediatrics, Chapter 7:

Patient and Family-centered Care)

Answer 1-21 e

By inviting patient and family members to participate in

a working group focused on improving an organizational

process, the hospital is demonstrating an awareness of the

importance of collaboration with families to improve the health

care system Pediatric hospital systems have shown the benefits

of collaboration with families including improved patient and

satisfaction scores and decreased cost

Answer a is incorrect because families are not given

an option to be present and, thus, the department is not

demonstrating flexibility to meet the individual needs of the

families Answer b is incorrect because the unit is excluding family members during important transitions of care and medical team interactions that would potentially benefit from family participation Answer c does not describe active participation of patients or family members in the development

of materials Answer d is incorrect because although the family advisors are members of the hospital committees, they are not actively involved as full participants with voting privileges (Page 19, Section 1: Fundamentals of Pediatrics, Chapter 7: Patient and Family-centered Care)

Answer b excludes some families from communicating with the medical team during team rounds as provided to other families of hospitalized children Families of children admitted for evaluation of child maltreatment still need medical information from the team, unless they lose custody

or rights to visitation from a state agency Answer c is incorrect because the families are excluded from decision making by the team and there is no evidence of collaboration with families to determine a care plan Answer e does not describe a collaborative approach to managing a child’s chronic disease, and does not demonstrate the physician’s willingness to partner with the family or provide choices in medical decision making

(Page 19, Section 1: Fundamentals of Pediatrics, Chapter 7: Patient and Family-centered Care)

Answer 1-23 c

Disaster preparedness consists of 4 phases that include preparedness (advanced planning), response (direct actions during the disaster), recovery (return to normalcy after acute event), and mitigation (actions to decrease the vulnerability

of a disaster and reduce the need to respond in a disaster) Pediatricians have a role in each of these components whether they are key players or community members Answer c is correct and is included in the preparedness phase Children with special health care needs have increased vulnerabilities because they require more rare medications and specialized equipment, and can be dependent on an electrical source for life-maintaining equipment such as ventilators Having a conversation with their caregivers in advance of a disaster and addressing all aspects of care and backup systems can prevent additional casualties caused by short supply of medications

or electricity failures A written disaster plan allows for all participants in the care of these children to ensure necessary supplies and equipment are available

Fundamentals of Pediatrics

Answer a is not the best answer because vaccination

prophylaxis should not be limited to just hepatitis A While it

is important to respond to lessons learned from prior disasters,

it would not be prudent to focus vaccination only on hepatitis

A Ideal mitigation of vaccine-preventable infectious diseases

would include proper immunization of all vaccine-preventable

diseases to minimize the population susceptibility from

increased herd immunity Answer b is incorrect because the

Incident Command System is a mechanism for collaborative

management This system allows for coordination of both

public and private emergency management agencies and

uses best practices to coordinate all resources and facilities

Local community leadership and stakeholders designate

representatives to participate in the Incident Command

System This system does not include every pediatrician but

does benefit from having a pediatric representative to address

the unique health care needs of children

Answer d is incorrect because disaster preparedness requires

physicians to be prepared to care for patients in a wide variety

of disaster situations to include natural, biological, traumatic,

nuclear, chemical, and humanitarian disasters ( Table 8-1 )

In this instance, hurricane disaster preparedness is essential

because of the increased likelihood, but this community is also

susceptible to disasters such as plane crashes, terrorist attacks,

pandemic infections, and others Answer e is not the best

answer because it is a very limited approach to the recovery

phase of disaster preparedness Posttraumatic stress disorder

is not an infrequent result of any disaster Pediatricians should

have a heightened suspicion for this in children who have

survived disasters, but the general pediatrician is not expected

to be able to diagnose and treat these patients The essential

role of a pediatrician is to recognize the signs and assist families

with accessing mental health services

(Page 21-23, Section 1: Fundamentals of Pediatrics, Chapter 8:

Disaster Preparedness)

Answer 1-24 c

Disaster is “a sudden calamitous event bringing great damage,

loss, or destruction,” which can include any event in which the

needs of a population exceed the local capacity to meet them

Children are uniquely affected because of their growth rate,

developmental level, and dependence on adults Answer c is

correct because the smaller the child, the larger the relative

quantity of contamination he or she is exposed to Children

have increased respiratory and increased metabolic rates in

relation to their weight when compared with adults

Answer a is incorrect and the opposite is true Young children

and fetuses are more susceptible to toxins because of their rapid

growth and early stages of development They also have a greater

potential time to live after the exposure, allowing for larger

cumulative effects and time to demonstrate long-term effects of

toxins Answer b is incorrect because children are susceptible

to developing posttraumatic stress disorder after a disaster It is

important for pediatricians to be aware of this, address it early,

and assist families with access to mental health services if it

is suspected Answer d is incorrect By helping parents learn

to talk with their children about violence, death, and disaster that occurs in our daily environment and addressing children’s fears, pediatricians can increase the resiliency of children to disasters Answer e is also incorrect because pediatricians are a valuable resource for disaster preparedness and recognize the unique challenges that families with children face Together, pediatricians and local health authorities can address a larger population regarding disaster preparedness than public health authorities alone Pediatricians are valuable and trusted liaisons

to the public for many issues that impact families

(Page 21-23, Section 1: Fundamentals of Pediatrics, Chapter 8: Disaster Preparedness)

Answer 1-25 c

While you may believe that Ms B is choosing a poor course of action for her child, and even though there are implications for schooling and pandemic quarantines when a child is not immunized, all states recognize that the scope of parental authority is quite broad with regard to many issues, including immunizations In fact, parental authority is trumped only when parents are abusive or medically negligent All 50 states allow medical exemptions for immunizations, and thus such refusals are not considered medical negligence As a result, answers d and e are incorrect Forty-eight of the 50 also allow religious and/or philosophical exemptions Answer a

is incorrect, as excusing this family from your practice may increase the chance that they will never be willing to get immunizations As a pediatrician, care and trustworthiness are paramount values to maintain Listening carefully to Ms B’s reasons, providing education, and maintaining a working relationship are your best hope of changing Ms B’s mind

A response similar to answer b, without understanding the parent’s source of information or perspective on this issue, may be off-putting One potential advantage of a primary care relationship and continuity of care is the potential opportunity

to revisit the issue of childhood immunizations at a future visit

It might be possible to get her to agree to some immunizations, even if she does not agree to all of them As a result, answer c is the best response

(Page 24-25, Section 1: Fundamentals of Pediatrics, Chapter 9: Law, Ethics, and Clinical Judgment)

Answer 1-26 a

Confidentiality is a paramount obligation for all health care providers Ethically, confidentiality demonstrates trustworthiness and protects patient privacy Legally, most states have statutory protections for confidentiality of minor patients with regard to their sexual health (making answer b incorrect), although statutes vary on what the exact protections are and whether/when a minor’s confidentiality can be broken However, strict confidentiality between physician and patient cannot be guaranteed (ruling out answer d) For example, if the patient uses her parents’ insurance to pay for the visit and treatment, that information will be reported to the insurance company and, thus, will be available to her parents Also,

answers a and b incorrect) Justin’s cut is large enough to require skillful closure, and since head trauma can have significant consequences if not diagnosed, both the closure and tests should be performed during the current visit In many states grandparents, and even babysitters, can give legally authorized consent for the treatment of a minor; however, neither is necessary in this case Further, it places a significant moral burden on the babysitter who may be in no better position to make the decision than the physician, and the time and effort to find the grandparents places an undue burden

on the hospital staff, the grandparents, and the patient himself (answer d is incorrect as well) Also, although some hospitals have policies allowing for “administrative” consent, this is rarely a type of consent recognized in the law (thus, answer c is incorrect) And again, emergent situations require physicians to act to stabilize the patient’s condition whenever there is no one otherwise authorized to make medical decisions for the patient (Page 24, Section 1: Fundamentals of Pediatrics, Chapter 9: Law, Ethics, and Clinical Judgment)

is reasonable to withhold final judgment on whether Bobby should be granted full decisional authority His parents, too, are not entirely convinced that Bobby is making the best choice Therefore, answers a and e are incorrect It is their desire to maintain a loyal and supportive relationship with their son that moves them not to oppose his position None of this speaks to initializing state intervention, but instead to strive for greater communication and the development of creative solutions Therefore, answer c is correct

(Page 25-26, Section 1: Fundamentals of Pediatrics, Chapter 9: Law, Ethics, and Clinical Judgment)

Answer 1-30 d

By being married, Nicole is an emancipated minor entitled to make her own medical decisions, as long as she has decisional capacity Thus, answer b is incorrect The question, then, is does this decision need to be made now? If so, her husband would be next of kin, and have decisional authority (this situation makes answers c and e incorrect, regardless)

However, while decisions like these cannot be put off indefinitely, and while maintaining the airway will be more complicated without a tracheostomy, the decision to have surgery is not so emergent More time can be given to see whether Nicole reaches a cognitive state where she can make the decision for herself

(Page 25, Section 1: Fundamentals of Pediatrics, Chapter 9: Law, Ethics, and Clinical Judgment)

certain transmittable diseases must be disclosed to state health

officials, who themselves—depending on the state and the

disease—may be required to disclose the patient’s condition

to specific individuals Further, as “mandated reporters” in

cases of suspected abuse, all pediatricians may have to tell

state authorities when they have suspicions that a patient

has been abused Finally, some mental health conditions,

such as suicidality, may require involuntary confinement and

evaluation Answer c is incorrect because state intervention is

not considered before it is warranted, and answer e is incorrect

because the response does not address the patient’s concern

for privacy It is best to both acknowledge the importance of

confidentiality and inform the patient of possible limits that

she should be aware of before she discloses anything to you

(Page 26, Section 1: Fundamentals of Pediatrics, Chapter 9:

Law, Ethics, and Clinical Judgment)

Answer 1-27 b

This scenario demonstrates a tension between respecting

parental values as they raise their children and providing

necessary medical treatments to protect the patient from

undue harms Answer c is incorrect because the surgery,

while important, even necessary, for Billy’s well-being, is

not emergent Further, Billy’s parents do not want harm to

come to Billy, and they do not object to the surgery, only the

use of blood (so answer e is incorrect) However, there is a

conflict because there is a strong likelihood that due to the

extensive surgery, Billy will require blood, and without the

administration of these blood products, Billy may die If Billy

were an adult with decisional capacity, he would have the

right to refuse medical interventions of any sort at any time

As a 12-year-old, Billy may be a bright, insightful boy, but

few would argue that he has reached a level of developmental

maturity to be covered by spirit of the mature minor doctrine

Thus, his wishes, while important to know, cannot be the

determining factor in this scenario (ruling out answer d)

In response to answer a, in the 1944 US Supreme Court

case Prince v Massachusetts , Justice Rutledge stated the now

famous legal principle that parents are entitled to make martyrs

of themselves, but not of their children The case itself was

not strictly about parental health care decisions, but as Justice

Rutledge notes, “The right to practice religion freely does

not include liberty to expose the community or the child to

communicable disease or the latter to ill health or death.”

Obtaining an ethics consult can allow the parents to air their

concerns more carefully, but if they continue both to want

surgery and to refuse blood products, the court order will be

necessary

(Page 24-25, Section 1: Fundamentals of Pediatrics, Chapter 9:

Law, Ethics, and Clinical Judgment)

Answer 1-28 e

While respect for parental decision-making authority is

important to maintain, under emergent conditions providing

necessary medical treatment for a child is paramount (making

Ada M Fenick

Health Promotion and Disease Prevention

CHAPTER 2

2-1 A “medical home” is:

a. The health parameters of the entire community

where a child lives and learns

b. A location for children with special health care

needs to live when their medical issues overwhelm

their parents

c. A psychological construct that describes the place

that children most feel at home discussing their

medical problems

d. The location in the house where the family does

most of their medical care, for example, bandaging

and distribution of medications

e. The place where health supervision occurs,

which optimally promotes health and builds

on the recognized strengths of the child and

family

2-2 Which of the following does not appear as a specific

area of importance in each Bright Futures age-based

visit?

a. Context (brief overview of developmental tasks and

milestones usually achieved at specific age levels)

b. Evidence (background papers and specific data from

randomized controlled trials regarding utility of the

recommendations)

c. Priorities for the visit (the concerns of the parents

and 5 additional topics for discussion in the visit)

d. Health supervision (special details of history, observation, developmental surveillance, physical examination, screening, and immunizations)

e. Anticipatory guidance (more detail for the visit priorities for the provider, specific health promotion questions, and information for the parent and child)

2-3 The most important priority topics in Bright Futures are:

a. Parental concerns

b. Nutrition and activity

c. Mental health issues of child and family

d. Injury prevention and health promotion

e. Developmental milestones

2-4 An 18-month-old toddler is in your office for a child visit In the last few visits, he has grown more apprehensive when you enter the room Which of the following techniques is most likely to calm him so that you can complete the physical examination?

well-a. Attempt to meet his gaze directly as soon as possible

b. Allow his mother to hold him on her lap

c. Perform the examination as soon as you enter the room

d. Examine him in the usual head-to-toe approach

e. Have his father firmly position him while you examine his ears

a. Obtain a bone age

b. Obtain blood and urine for preliminary failure to

thrive tests

c. Obtain an extensive dietary history

L E N G T H

L E N G T H

W E I G H T

W E I G H T

Birth 3 6 9

Birth 3 6 9 12 15 18 21 24 27 30 33 36

2 3 4 5 6 7

10 12 14 16

8 6

kg lb

AGE (MONTHS)

12 15 18 21 24 27 30 33 kg

Mother’s Stature Father’s Stature

90 95 100

cm

100

lb

16 18 20 22 24 26 28 30 32 34 36 38

40 45 50 55 60 65 70 75 80

90 95 85

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

41 40 39 38 37 36 35

Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000).

95 75 50 25 10 90

AGE (MONTHS)

X X X X X X

X X X X X X

d. Replot these growth points on the World Health Organization (WHO) growth charts

e. Reassure the parents that this growth pattern is normal

2-5 A 12-month-old breastfed female arrives in your office

for well-child care After your nurse is done weighing

the child, you review the growth chart What is your next step?

Health Promotion and Disease Prevention

2-6 Visit closure would be unlikely to include:

a. Reviewing high-priority areas that were discussed in

the visit

b. Handing out pamphlets and tip sheets

c. Modeling positive reinforcement techniques

d. Creating the plan for the next visit

e. Giving a Reach Out and Read book

2-7 You wish to improve identification of obesity in your

practice You convene a team of physicians, nurses, and

front desk staff, and discover through baseline data

collection that you are identifying the weight status

of 40% of your patients You decide that the nurses

will place a sticky note on all charts where the child’s

growth points fall at greater than the 95th percentile,

prompting you to enter a diagnosis in the problem list

After 1 week, you review the charts again and note

that you are now up to 60% identification You note

the improvement, but want a higher level of fidelity,

and you decide to alter your plan to having the nurses

flag children when they are at greater than the 85th

percentile Which part of your described activities

comprised the “study” segment of the plan–do–study–

act (PDSA) cycle?

a. Discover through baseline data that you are

identifying the weight status of 40% of patients

b. Decide that the nurses will place a sticky note on

all charts where the growth is greater than the 95th

e. Have the nurses flag children when they are at

greater than the 85th percentile

2-8 You are giving a presentation about child development

to a parent–teacher organization You are asked about

the concept of “resilience” in relation to development

Resilience is:

a. Any external, environmental factor that promotes

child development

b. A physical characteristic; specifically, the ability for a

child to withstand corporal punishment or physical

abuse

c. A characteristic that is inherent and present in equal

amounts in all children

d. A relative resistance to environmental risk experiences, or overcoming stress or adversity

e. A characteristic not associated with optimism

2-9 A 30-month-old arrives for well-child care His medical history includes intermittent asthma His mother is concerned about slow motor development; she says that he can’t jump or walk up stairs one foot at a time Which of the following would be a risk factor for poor motor development?

a. The bedtime routine includes nightly reading by a parent

b. You observe that child is checking back with the mother frequently during his exploration of the room

c. You recall that the mother and an older sibling of this child have a strong relationship

d. You review the chart and note a history of prematurity, with birth at 31 weeks EGA

e. The child scores in the gray area on the Ages and Stages Questionnaire for gross motor skills

2-10 The motherhood constellation is:

a. The people around a new mother who provide emotional and physical assistance

b. A mental state of a mother in which she prioritizes the infant and her relationship with the infant

c. A group of symptoms and signs of pregnancy, including amenorrhea, morning nausea, breast enlargement, and mild weight gain

d. The people with whom a mother interacts on a regular basis, whether or not they provide support

e. A group of early symptoms of postpartum depression, such as insomnia, poor appetite, and mild sadness

2-11 Which of the following is unnecessary to secure attachment between a child and her parent?

a. Parents’ provision of age-appropriate toys

b. Parents’ emotional availability

c. Ability of parents to manage their own state of arousal

d. High parental sensitivity

e. Appreciation of the infant’s needs as independent of the parents’ own